Antibiotics Malaysia

Research Article

A Cross Sectional Study of Public Knowledge and Attitude towards Antibiotics in Putrajaya, Malaysia

AbstractObjective: The objective of the study was to assess public knowledge and attitudes regarding antibiotic utilization in Putrajaya,

Malaysia.

Methods: A self-administered questionnaire survey was conducted among public attending a local hospital. The four-part questionnaire

collected responses on demographic characteristics, recent use of antibiotics, knowledge and attitude statements. Cronbach’s alpha

for knowledge and attitude statements were 0.68 and 0.74 respectively. Only questionnaires with complete responses were analysed.

General linear modelling was used to identify demographic characteristics which contributed significantly to knowledge and attitude.

Multiple logistic regression was used to determine the adjusted odds ratios of obtaining an inappropriate response for each knowledge

and attitude statement. The relationship between antibiotic knowledge and attitude was examined using Pearson’s correlation and

correlation between related statements was performed using the Chi-square test. In all statistical analyses, a p-value of < 0.05 was

considered statistically significant.

Results: There was positive correlation (p<0.001) between mean knowledge (6.07±2.52) and attitude scores (5.59±1.67). Highest

education level (p<0.001) and healthcare-related occupation (p=0.001) contributed significantly to knowledge. Gender (p=0.010), race

(p=0.005), highest education level (p<0.001), employment status (p=0.016) and healthcare-related occupation (p=0.005) contributed

significantly to attitude. The differences in score between demographic groups were small. Misconceptions that antibiotics would work

on both bacterial and viral infections were reported. Approximately three quarters of respondents expected antibiotics for treatment

of coughs and colds. Close to two thirds (60%) believed that taking antibiotics would improve recovery. Several demographic groups

were identified as ‘high risk’ with respect to gaps in knowledge and attitude.

Conclusions: This study has identified important knowledge and attitude gaps as well as people ‘at risk’. These findings would be

useful in strategizing targeted antibiotic awareness campaigns and patient counselling.

Keywords: antibiotic, attitude, knowledge, Malaysia, public, survey

26

ReviewSouthern Med

Ka Keat Lim1, Chew Charn Teh2

1Healthcare Statistics Unit, Clinical Research Centre, Ministry of Health, Malaysia.

2Department of Pharmacy, Tengku Ampuan Rahimah Hospital, Ministry of Health, Malaysia.

Address for Correspondence: Ka Keat Lim, Clinical Research Centre, Ministry of Health Malaysia, 3rd Floor, MMA House, 124 Jalan Pahang, 53000 Kuala Lumpur, Malaysia. E-mail: [email protected]

IntroductionEmergence of antibiotic resistance has become a global

public health concern in recent decades. Studies in Europe

[1,2] indicate that resistance against antibiotics increases with

higher consumption, which could be driven by irrational use of

antibiotics and insufficient patient education by prescribers. [3]

While antibiotic utilization in Malaysia (9.65 defined daily doses

(DDD) / 1000 population / day) [4] is low compared to European

countries such as Norway (16.16), Denmark (17.8), France

(21.56) and Finland (30.85) [5], the country is not free from

the issue of antibiotic resistance. In fact, in 2010, the National

Surveillance on Antibiotic Resistance [6] reported an increase of

antibiotic resistance among common strains of bacteria such

as Staphylococcus aureus, Acinebacter and Haemophilus

influenzae.

According to the Malaysian National Medicine Use Survey

(NMUS) 2007, antibiotics were the 11th most utilised therapeutic

Southern Med Review Vol 5 Issue 2 December 2012

Citation: Lim KK, Teh CC. A Cross Sectional Study of Public Knowledge and Attitude towards Antibiotics in Putrajaya, Malaysia. Southern Med Review (2012) 5;2:26-33

Received: 19th Aug 2012Accepted: 17th Dec 2012Published Online: 27th Dec 2012

group in Malaysia and accounted for the largest proportion

of money spent in 2006 and 2007 [4]. The most widely used

antibiotic class was the penicillin [4]. Several local studies

reported upper respiratory tract infections as the most common

infections to be prescribed antibiotics in hospitals (31%) [7] and

primary care (50 – 55.2%) [8,9]. Inappropriate prescribing of

antibiotics and poor patient knowledge were observed in many

of these studies [7–10]. In another study [11], only 21.4% of

survey respondents were able to understand antibiotic usage

instructions on the labels. The only Malaysian study assessing

public knowledge and attitude towards antibiotics was

conducted in the northern state of Penang, and revealed a

sizeable proportion of respondents having poor knowledge and

attitude towards antibiotics [12].

The World Health Organization (WHO) issued a Global Strategy

for Containment of Antimicrobial Resistance in 2001 which

urged member countries to initiate awareness and educational

campaigns for patients and general community on appropriate

use of antibiotics to combat antibiotic resistance [13]. This was

echoed by International Pharmaceutical Federation (FIP) in 2008

in its Statement of Policy on Control of Antimicrobial Drug

Resistance [14] and WHO Regional Office for South-East Asia

[15] in 2010. In line with these recommendations [13–15] and in

view of the lack of evidence in Malaysia the study was designed

and carried out among public members in Putrajaya, a federal

government administrative city located about 25km south of

Kuala Lumpur. In 2010, Putrajaya was home to an estimated

85,636 people. [16]

The objective of this study was to assess public knowledge and

attitude regarding antibiotic utilization in Putrajaya, Malaysia.

The study is registered in the National Medical Research Register

(ID: NMRR-12-8-10849).

MethodsQuestionnaire Development and Structure

A questionnaire was used to gather public responses. A four-

part questionnaire was adapted and modified from previous

studies [12, 17–19]. Part I recorded a total of 9 demographic

characteristics and Part II documented respondents’ recent

antibiotics consumption (defined as antibiotic use within

the past four weeks). Part III was made up of 12 knowledge

statements covering five aspects including: identification of

antibiotics, action of antibiotics, good bacteria, adverse effects

of antibiotics and administration of antibiotics. Participants

were asked to respond with either “Yes”, “No” or “Not Sure”.

Part IV contained eight attitude statements and respondents

were required to answer according to a 5-point Likert scale

(1=strongly disagree; 2=disagree; 3=not sure; 4=agree and

5=strongly agree). Part IV was adopted wholly from a previous

study [12].

The questionnaire was originally developed in English, which was

then translated into Malay language (the national language of

Malaysia). Face and content validation of the questionnaire was

undertaken by a panel of senior hospital pharmacists. Feedback

was gathered to improve the questionnaire presentation, clarity

and congruency of meaning. Modifications were made and the

questionnaire was pilot-tested among 30 respondents. Pilot

testing was carried out based on the feedback from the first

round and reliability testing was also conducted. Cronbach’s

alpha for Part III and Part IV of the questionnaire were 0.68 and

0.74 respectively.

Study Design and Administration of Questionnaire

The study was conducted over 6 weeks in February and March

2010 using the validated questionnaire. Respondents were

attendees of the outpatient pharmacy department of Putrajaya

Hospital. Sample size was determined using the Raosoft sample

size calculator [20] for the population of 116,000 people

attending Putrajaya Hospital annually. A sample size of 383 was

required to provide a confidence level of 95%.

Along with a confidentiality statement and paragraph

explaining the objectives of the study, 520 self-administered

questionnaires were distributed to account for potential non-

response. A convenience sampling method was adopted. The

inclusion criteria were: (1) Adults aged 18 years and over; (2)

able to read and understand Malay or English and (3) aware

of the term ‘Antibiotics’. Verbal consent was obtained from all

study participants before administering the questionnaire. No

personal identifiers were included in the form.

Statistical Analysis

Only fully completed questionnaires were included in the

analysis. Numerical data were expressed as mean ± standard

deviation. Respondents’ age was categorised into four groups

“18–30”, “31-45”, “46-60” and “61 and above”. “Appropriate

responses”, defined as correct answers for Part III and positive

attitude for Part IV were given 1 score as opposed to 0 score for

“inappropriate responses”, defined as either incorrect answers,

negative attitude or “Not Sure”.

All data were analysed using SPSS® version 20.0. Demographic

characteristics, recent use of antibiotics, knowledge and

attitude scores were summarised using descriptive statistics. The

difference between mean scores was examined by using t-test

or ANOVA where appropriate. Demographic characteristics

which contributed significantly to knowledge and attitude were

identified using a general linear model (GLM). The adjusted

odds ratios (AORs) of obtaining an inappropriate response for

each knowledge and attitude statement were determined using

multiple logistic regressions. Pearson’s correlation was used to

examine the relationship between antibiotic knowledge and

attitude. Correlation between related statements was performed

using Chi-square test. In all statistical analyses, a p-value of <

0.05 was considered to be statistically significant.

ResultsOut of 520 questionnaires distributed, 508 questionnaires were

returned (97.7% response), of which 107 questionnaires were

incomplete. The final sample included 401 questionnaires.


27Southern Med Review Vol 5 Issue 2 December 2012

Respondents’ demographic characteristics are summarised

in Table 1. The mean age of the respondents was 41.1 ±

13.8 years old, with most falling within the 31-45 age group.

Most respondents were Malay (77.1%), female (63.8%), had

undertaken tertiary education (62.1%) and were wage-earners

(64.6%). A minority of respondents worked in health-related

occupation (11.0%), as did their family members (23.9%).

Only characteristics with significant difference (p < 0.05) in

mean scores were included in the general linear model (Table

1). After adjustment, highest education level (p<0.001) and

healthcare-related occupation (p=0.001) were found to

contribute significantly to the mean knowledge score whereas

gender (p=0.010), race (p=0.005), highest education level

(p<0.001), employment status (p=0.016) and healthcare-related

occupation (p=0.005) were found to contribute significantly to

mean attitude score.

Sixty six respondents (16.5%) reported taking antibiotics within

the past four weeks of the survey; most of whom obtained

their medicines after consultation with doctors. Three admitted

to purchasing antibiotics from retail pharmacy without prior

consultation. The most common reason cited for taking

antibiotics was respiratory tract infections (31.4%), which was

defined as either cold, cough or flu, followed by fever (29.1%),

others (12.8%), pain or inflammation (10.5%), skin problems or

wounds (8.1%) and urinary tract infections (8.1%). Respondents

who cited “Others” specified eye infection, ear infection, tooth

infection or post-operative use as their reasons for consuming

antibiotics.

The knowledge score ranged from 0 to 12 points, with a mean

of 6.07 ± 2.52 and a median of 6.00. Highest inappropriate

response was observed for statements on role of antibiotics. The

majority of respondents did not know that antibiotics would

not work against viral infections (83.0%) and most coughs and

colds (82.0%). On the other hand, the majority (82.5%) seemed

to be aware that antibiotics may cause allergic reactions; about

half of them (52.1%) did not know antibiotics could also cause

side effects. Knowledge on antibiotic resistance was also low

(Table 2).

The statement “It is okay to stop taking antibiotics when

symptoms are improving” was strongly associated with the

statements “Antibiotics are the same as medications used

to relieve pain and fever such as aspirin and paracetamol”

(p<0.001) and “Taking less antibiotic than prescribed is more

healthy than taking the full course prescribed.” (p<0.001).

The attitude score ranged from 0 to 8 points, with a mean

score of 5.59 ± 1.67 and a median of 6.00. The percentage of

inappropriate responses for the eight attitude statements are

summarised in Table 3.

Table 1: Respondents’ demographic characteristics



CharacteristicsMean

Knowledge Score ± S.D

pvalue

Mean Attitude Score

± S.D

pvalue

Gender

Female (n = 256) 6.31 ± 2.450.012

5.79 ± 1.530.002

Male (n = 145) 5.64 ± 2.59 5.23 ± 1.84

Age(years old)

> 60 (n = 37) 6.73 ± 2.92

0.329

6.27 ± 1.74

0.06246 – 60 (n = 107) 6.16 ± 2.37 5.61 ± 1.62

31 – 45 (n = 144) 5.96 ± 2.42 5.49 ± 1.73

18 – 30 (n = 113) 5.90 ± 2.64 5.47 ± 1.57

Race

Malay (n = 309) 6.00 ± 2.46

0.353

5.46 ± 1.64

0.003Chinese (n = 46) 6.67 ± 2.44 6.39 ± 1.42

Indian (n = 31) 6.03 ± 2.83 5.81 ± 1.92

Others (n = 15) 5.67 ± 3.2 5.27 ± 1.67

HighestEducat

-ion Level

College / University (n = 249)

6.62 ± 2.41

0.000

5.86 ± 1.56

0.000Secondary School

(n = 128)5.21 ± 2.35 5.10 ± 1.72

Primary School (n = 17)

4.53 ± 2.53 5.35 ± 1.69

None (n = 7) 5.86 ± 3.98 5.29 ± 2.63

Employ-mentStatus

Employed for Wages

(n = 259)6.11 ± 2.48

0.643

5.61 ± 1.66

0.031

Self employed (n = 29)

5.48 ± 2.69 4.79 ± 1.50

Housewife / Househusband

(n = 32)6.41 ± 2.30 5.88 ± 1.68

Retired / Unemployed

(n = 60)6.10 ± 2.73 5.85 ± 1.70

Student (n = 21) 5.76 ± 2.55 5.14 ± 1.62

Is your occupation related to

health-care?

Yes (n = 44) 7.34 ± 3.06

0.004

6.43 ± 1.42

0.000

No (n = 357) 5.91 ± 2.41 5.48 ± 1.67

Is your family’s

occupation related to

health-care?

Yes (n = 96) 6.49 ± 2.47

0.058

5.86 ± 1.67

0.062

No (n = 305) 5.93 ± 2.53 5.50 ± 1.66

What is your most common location seeking health-care?

Govt. Clinic / Hospital (n = 289)

6.08 ± 2.51

0.268

5.56 ± 1.69

0.182

Private Clinic / Hospital (n = 92)

5.85 ±2.64 5.51 ± 1.53

Pharmacy (n = 20)

6.85 ± 2.08 6.25 ±1.89

Others (n = 0) - -

Do you have any chronic

disease?

Yes (n = 142) 6.16 ± 2.580.582

5.73 ± 1.560.181

No (n = 259) 6.02 ± 2.50 5.51 ± 1.72

Table 2: Proportion of inappropriate responses for knowledge statements, compared to that for similar statements from other studies.



No. StatementCurrent

Study (%)

N=401

Oh et al (%)12

N=408

McNulty et al (%)17

N=7120

Chen et al (%)18

N=1024

Role of Antibiotics

1. Antibiotics are medicines that can kill bacteria. 21.7 23.3 20.0* -

2. Antibiotics can be used to treat viral infections. 83.0 86.6 ± 53.0* -

3. Antibiotics work on most colds & coughs. 82.0 - 38.0 -

Good Bacteria4.

Antibiotics can kill bacteria that normally live on the skin and gut (digestion tract).

60.3 - 43.0* -

5. Bacteria that normally live on the skin and in the gut are good for your health. 73.1 - ± 42.0 -

Idenfitication of Antibiotics

6.Antibiotics are the same as medications used to relieve pain and fever such as aspirin and paracetamol (Panadol).

33.4 - - -

7. Penicillin is an antibiotic. 61.8 54.9 - -

Adverse Effects

8. Antibiotics may cause allergic reactions. 17.5 46.0 - -

9. Antibiotics do not cause side effects. 52.1 54.4 - -

10.Overuse of antibiotics can cause the antibiotics to lose effectiveness in long term.

32.2 40.9* - -

Administration of Antibiotics

11. It is okay to stop taking an antibiotic when symptoms are improving. 41.9 28.9* - 49.9*

12.Taking less antibiotic than prescribed is more healthy than taking the full course prescribed.

33.2 - - 92.6*

* Statements were not exactly the same as that in this study.

Nearly half of the respondents (45.6%) would stop an

antibiotic course when their symptoms improved. Meanwhile,

seventeen percent of respondents reported sharing their

antibiotics with family members and would store antibiotics at

home for emergency use. A small percentage of respondents

demonstrated little caution when consuming antibiotics. In

particular, seven percent did not check expiry dates and fewer

again (3.5%) reported not taking antibiotics according to

labelled instructions. Strong association was observed between

respondents who would expect an antibiotic prescription for the

common cold and those who thought antibiotics were effective

in treating coughs and colds (p<0.001).

Table 3: Proportion of inappropriate responses for attitude statements, compared to that for similar statements from other studies.

No. StatementCurrent

Study (%)

N=401

Oh et al (%)12

N=408

Chen et al18 (%)

N=1204

Vanden Eng et al (%)19

N=12755

1. When I get cold, I will take antibiotics to help me get better more quickly. 61.8 46.8 - 36.9*

2. I expect antibiotic to be prescribed by my doctor if I suffer from common cold symptoms. 73.8 57.8 24.9* 53.6*

3. I normally stop taking an antibiotic when I start feeling better. 45.6 40.2 - -

4. If my family member is sick I usually will give my antibiotic to them. 17.0 11.8 13.1* -

5. I normally keep antibiotic stock at home in case of emergency. 17.0 19.9 - -

6. I will use leftover antibiotics for a respiratory illness (runny nose/ sore throat / flu). 14.7 11.5 - -

7. I will take antibiotic according to the instruction on the label. 3.5 6.9 4.5* -

8. I normally will look at the expiry date of antibiotic before taking it. 7.0 7.8 - -

* Statements were not exactly the same as that in this study



Significant positive correlation was noted between respondents’

antibiotic knowledge score and their attitude score (r = 0.462,

p<0.001). The AORs for knowledge and attitude statements

are found in Table 4 and 5 respectively, with demographic

characteristics. People in younger age groups, with secondary

education or lower and male were found to have higher

odds of poor knowledge on adverse reactions, administration

of antibiotics, and attitute statements (Table 4). Those in the

younger age groups were more likely to report taking antibiotics

to recover more quickly, to expect antibiotics for common cold

and to stop antibiotics when symptoms improve. Respondents

with primary and / or no education were those who reported

less caution in using leftover antibiotics and not using antibiotics

according to instructions on the label (Table 5).

Table 4: Factors associated with inappropriate response for each knowledge statements.

Statement 1 2 3 4 5 6 7 8 9 10 11 12

GenderFemalea 1 1 1 1 1 1 1 1 1 1 1 1

Male 1.577 0.936 1.787 0.867 0.900 1.319 1.261 2.381 1.704 1.712 2.120 1.820

Age

More than 60a 1 1 1 1 1 1 1 1 1 1 1 1

46 – 60 3.247 1.114 0.889 1.902 1.726 0.975 1.308 0.930 1.141 1.580 2.328 1.098

31 – 45 2.489 1.940 1.662 1.597 2.881 1.018 0.941 2.648 1.207 2.454 3.020 2.269

18 – 30 2.837 2.249 0.804 1.770 2.475 1.177 0.974 5.071 1.774 4.346 2.976 2.566

Race

Malaya 1 1 1 1 1 1 1 1 1 1 1 1

Chinese 0.612 1.327 0.818 0.482 0.528 2.107 5.734 0.263 0.153 0.990 0.748 1.264

Indian 1.519 0.934 1.165 0.957 1.265 1.108 1.054 0.712 0.256 1.402 0.850 0.900

Others 0.510 1.392 6.178 2.897 0.629 0.849 0.658 0.674 0.353 1.325 0.298 0.517

Highest Education Level

University / Collegea 1 1 1 1 1 1 1 1 1 1 1 1

Secondary 3.076 1.329 0.837 4.322 2.107 1.078 1.832 2.168 1.726 2.044 3.405 3.140

Primary 5.662 2.594 1.497 1.574 1.071 0.938 1.040 2.847 2.701 8.686 5.076 5.134

None 2.255 2.823 1.567 2.511 1.252 1.757 1.037 6.407 0.537 2.415 5.991 4.429

Employment Status

Employed for wagesa 1 1 1 1 1 1 1 1 1 1 1 1

Self-employed 1.943 1.121 0.920 1.014 1.725 0.870 0.944 0.436 1.010 1.495 1.835 1.261

Housewife / Househusband

0.630 1.200 0.285 0.522 1.214 0.782 1.417 0.891 0.381 0.749 2.454 0.614

Retired / Unemployed 0.684 1.277 0.764 1.729 2.868 0.519 1.014 1.899 1.628 0.934 0.967 1.427

Student 1.491 2.130 0.536 2.469 0.736 1.785 1.329 0.840 0.592 2.151 1.190 0.536

Is your occupation related to

healthcare?

Yesa 1 1 1 1 1 1 1 1 1 1 1 1

No 1.082 3.076 1.162 5.341 2.185 1.116 2.072 1.615 1.929 1.712 1.215 1.392

Is your family’s occupation related to

healthcare?

Yesa 1 1 1 1 1 1 1 1 1 1 1 1

No 0.802 1.053 0.984 0.518 0.810 1.644 1.480 0.796 0.990 1.509 1.048 1.385

What is your most common

location seeking

healthcare?

Government Clinic /

Hospitala1 1 1 1 1 1 1 1 1 1 1 1

Private Clinic /

Hospital1.139 1.062 1.553 0.696 1.178 1.850 0.979 0.901 0.660 0.801 0.816 1.600

Pharmacy 0.519 1.018 0.963 0.287 5.233 1.644 0.361 0.000 0.616 0.705 0.681 0.465

Do you have any long term

diseases?

Yesa 1 1 1 1 1 1 1 1 1 1 1 1

No 0.867 0.991 0.826 1.670 0.992 1.324 1.103 0.950 0.645 0.746 1.471 1.098

aReference group of the categorical variable.Odds ratios were adjusted for all variables. The odds ratios were obtained by stepwise multiple logistic regression analyasis. Statistically significant variables are in bold.



Table 5: Factors associated with inappropriate response for each attitude statement.

Statement 1 2 3 4 5 6 7 8

GenderFemalea 1 1 1 1 1 1 1 1

Male 1.777 1.670 1.753 2.012 2.162 2.507 2.628 1.564

Age

More than 60a 1 1 1 1 1 1 1 1

46 – 60 2.862 2.152 2.306 1.355 0.766 1.243 6.537 2.684

31 – 45 4.697 3.571 3.125 2.523 1.623 3.185 5.006 0.702

18 – 30 5.466 4.484 3.620 2.779 1.845 3.164 1.154 1.083

Race

Malaya 1 1 1 1 1 1 1 1

Chinese 0.203 0.313 0.300 0.886 1.212 1.285 4.869 1.336

Indian 0.523 0.313 0.759 0.675 1.026 1.323 2.021 1.238

Others 0.942 0.759 0.617 1.619 2.760 1.365 0.000 2.558

Highest Education Level

University / Collegea 1 1 1 1 1 1 1 1

Secondary 1.855 3.385 3.218 1.981 1.530 1.651 4.487 0.737

Primary 1.356 1.472 2.404 2.109 1.677 1.607 16.373 0.828

None 1.468 1.489 2.815 4.867 1.293 12.012 26.687 4.984

Employment Status

Employed for wagesa 1 1 1 1 1 1 1 1

Self-employed 3.049 2.698 1.914 0.866 1.385 1.880 3.442 2.371

Housewife / Househusband 2.215 1.043 0.894 0.730 0.602 0.446 1.299 0.196

Retired / Unemployed 1.971 1.648 1.221 0.817 0.697 2.104 0.851 0.597

Student 2.480 2.792 1.611 1.697 2.343 0.214 0.000 3.984

Is your occupation related to healthcare?

Yesa 1 1 1 1 1 1 1 1

No 1.951 3.014 1.723 1.273 1.184 1.553 1.284e8 1.259e8

Is your family’s occupation related

to healthcare?

Yesa 1 1 1 1 1 1 1 1

No 1.283 1.854 1.157 1.168 1.163 0.721 0.538 0.971

What is your most common location

seeking healthcare?

Government Clinic / Hospitala 1 1 1 1 1 1 1 1

Private Clinic / Hospital 0.741 0.842 1..126 1.120 0.739 0.755 1.231 2.068

Pharmacy 0.454 0.360 0.389 0.489 0.416 0.610 6.301 2.584

Do you have any long term diseases?

Yesa 1 1 1 1 1 1 1 1

No 0.744 0.690 1.285 1.815 1.450 1.455 1.214 1.265aReference group of the categorical variable.Odds ratios were adjusted for all variables. The odds ratios were obtained by stepwise multiple logistic regression analyasis. Statistically significant variables are in bold.

DiscussionAntibiotic Use

Only 16.5% of respondents reported using antibiotics within the

past month which was lower than the 28.9% reported in the

northern state of Penang [12]. However, the main indications

reported in this survey and the Penang survey were similar,

with respiratory tract infections and fever being the main ones.

It was still possible for the public to obtain antibiotics without

prescriptions even though this practice is illegal. (Table 1)

Compared to 7.5% reported in Penang [12] and 9.0% reported

in Hong Kong [21], the proportion of respondents who did so in

this study was lower (4.5%).

The Knowledge and Attitude Gaps

The results suggest that misunderstandings about antibiotic use

were prevalent, which may cause unneccessary risk of antibiotic-

resistant infection. Confusion about the role of antibiotics in

treating infections was the most critical, with more than 80% of

respondents failing to identify that antibiotics do not eradicate

viral infections. This is consistent with the study in Penang

(86.6%) [12]. In contrast, the proportion was reported to be

53.0% in a UK study [17]. Thirty eight percent of respondents

from the UK study [17] thought antibiotics would be effective

for treating most coughs and colds, compared to 83.0% in

this study. The significant correlations between knowledge

statements 6, 11 and 12 indicate that the knowledge gap

might not be totally random. Respondents might have mistaken

antibiotics as equivalent to painkillers or antipyretics, leading

them to assume that stopping antibiotics is okay, as they would

do with painkillers and antipyretics with symptom improvement.

The prevalence of inappropriate attitudes was higher compared

to previous work [12,17,18]. In particular, more respondents

from this survey reported that they would take antibiotics to help

them recover faster, would expect antibiotics to be prescribed

by a doctor for the common cold, would stop antibiotics when

they start to feel better, would share antibiotics with sick family

members and would use left-over antibiotics for treating future

respiratory illnesses (Table 3).

Factors that were expected to have huge impact on knowledge

and attitude, such as higher education level, race and increased

age showed only a maximum of 2.1 score difference. Education

level has been reported as a factor significantly associated with

both knowledge [12,21] and attitude [21] on antibiotics. A local

study found ethnicity to contribute significantly to knowledge

on antibiotics [12].

Respondents’ knowledge of appropriate antibiotic use was

found to correlate postively with attitude. Strong association

was also observed between several knowledge and attitude

statements. This was consistent with a study in Korea, where

adequate knowledge of antibiotics was shown to be a predictor

for appropriate attitudes toward antibiotics and their use where

participants with adequate knowledge were 1.52 times more

likely to demonstrate appropriate attitude [22].

The ‘High Risk’ Group

This survey identified demographic groups who were prone to

misconceptions and efforts to reach these groups of people

should be a part of future educational campaigns. For instance,

respondents without tertiary education may benefit from

education about antibiotics only being effective for bacterial

infections and not viruses.

Targeted Antibiotic Campaign and Counselling

An antibiotic campaign was launched in 1999 in the UK targeting

young women and mothers who had higher consultation rates

than other patients [23]. Its success in raising awareness on

antibiotic resistance and reducing expectations for antibiotics

had led the campaign being repeated in 2002. In Malaysia, it

would be worth considering such a campaign at least at a local

level. The Know Your Medicine Campaign [24] launched jointly

by the Ministry of Health and Consumers Association of Malaysia

in 2007 was a positive start and demonstrated willingness on

the part of policy-makers but also providers at grassroot levels

to promote prudent medicine usage among the public.

Previous work has reported members of the public not

identifying with bacterial resistance as a personal threat and

feel they have no role in managing the risk associated with it

[25]. Hence, a targeted antibiotic campaign should aim to make

members of the public, particularly those from the ‘high risk’

groups identified in this study feel that they have an influence

in overcoming antibiotic resistance. Successful implementation

of a nationwide campaign could potentially lead to sustained

reduction of antibiotic utilization and lower bacterial resistance

[26,27]. On another level, healthcare professionals also have the

responsibily of providing proper counselling to these “high risk”

patients. Effective doctor-patient communication and patient

empowerment have been shown to reduce antibiotic prescribing

for coughs and colds in the primary care setting [28]. Besides the

knowledge, instilling the right attitude should also be a priority

as simply increasing public knowledge on antibiotics has been

shown to cause higher incidences of self-medication [17].

LimitationsThere are several limitations in this study. Similar to all self-

administered public surveys, the accuracy of the results was

heavily dependent on the honesty and understanding of the

respondents. Selection bias might occur due to convenience

sampling. As the study was conducted in a local hospital

setting, the findings may not be generalised to the whole

country or other sectors of health care. The survey methodology

omitted respondents who could not understand English or

Malay language and those who had no awareness of the term

“antibiotic”.

ConclusionThe study identified important knowledge and attitude gaps as

well as people ‘at risk’. Future antibiotic awareness campaigns

and patient counselling should promote specific messages

to public members from the ‘high risk’ groups, to fill up the

knowledge and attitude gaps as an effort against antibiotic

resistance.

Authors’ ContributionsKK Lim had the original idea for the study. Both KK Lim and

CC Teh designed the questionnaire and carried out the data

collection. KK Lim carried out the data analysis and wrote the

first draft of the paper. All authors contributed to the revision of

the paper and approved the final version.

AcknowledgementsWe would like to thank the Director General of Health Malaysia

for the permission to publish this manuscript. We would like

to express our gratitude to our colleagues from Outpatient

Pharmacy Department of Putrajaya Hospital for their assistance

and cooperation throughout the survey. We would also like

to thank Mohamad Adam bin Bujang from Clinical Research

Centre for his consultation and advices on statistical analysis.

Conflict of InterestNone.

Funding SourceNo source of funding was used to assist in the preparation of

the study.

References1. Bronzwaer SLAM, Cars O, Buchholz U, Mölstad S, Goettsch

W, Veldhuijzen IK, Kool JL, Sprenger MJW, Degener JE and participants in the European Antimicrobial Resistance Surveillance System. The relationship between antimicrobial use and antimicrobial resistance in Europe. Emerg Infect Dis. 2002 March; 8(3): 278 – 282.



2. Goossens H, Ferech M, Stichele RV, Elseviers M for the ESAC Project Group. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005 February 12; 365(9459): 579 – 587.

3. Franco BE, Altagracia Martínez M, Sánchez Rodríguez MA, Wertheimer AI. The determinants of the antibiotic resistance process. Infect Drug Resist. 2009; 2: 1 – 11.

4. Pharmaceutical Services Division and Clinical Research Centre, Ministry of Health Malaysia. Malaysian Statistics on Medicine 2007. Kuala Lumpur: The National Medicines Use Survey; 2010.

5. European Surveillance of Antimicrobial Consumption (ESAC). Core Data Collection. Belgium: ESAC; [cited 2011-11-06] Available from: http://www.esac.ua.ac.be/main.aspx?c=*ESAC2&n=50221

6. Institute for Medical Research. National Surveillance on Antibiotic Resistance Report 2010. Kuala Lumpur: Ministry of Health Malaysia; 2010 [cited 2011-01-10] Available from: http://www.imr.gov.my/report/Summary%20of%20National%20Survei l lance%20of%20Antibiot ic%20Resistance%20report%202010.pdf

7. Lim VK, Cheong YM, Suleiman AB. Pattern of antibiotic usage in hospitals in Malaysia. Singapore Med J. 1993 December; 34(6): 525 – 528.

8. Teng CL, Achike FI, Phua KL, Norhayati Y, Nurjahan MI, Nor AH, Koh CN. General and URTI-specific antibiotic prescription rates in a Malaysian primary care setting. Int J Antimicro b Agents. 2004 November; 24(5): 496-501.

9. Teng CL, Leong KC, Aljunid SM, Cheah M. Antibiotic prescription in upper respiratory tract infections. Asia Pac Fam Med. 2004; 3(1-2): 38 – 45.

10. Scott JG, Cohen D, DiCicco-Bloom B, Orzano AJ, Jaen CR, Crabtree BF. Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription. J Fam Pract. 2001 October; 50(10): 853 – 858.

11. Hassan Y, Abd Aziz N, Sarriff A, Darwis Y, Ibrahim P. Comprehension of antibiotic instructions in an outpatient Malaysian practice. Hosp Pharm. 1994 January; 29(1): 48 – 50, 53.

12. Ling Oh A, Hassali MA, Al-Haddad MS, Syed Sulaiman SA, Shafie AA, Awaisu A. Public knowledge and attitudes towards antibiotic usage: a cross-sectional study among the general public in the state of Penang, Malaysia. J Infect Dev Ctries. 2011 May 28; 5(5): 338 – 347.

13. World Health Organization WHO/CDS/CSR/DRS/2001.2. WHO Global Strategy for Containment of Antimicrobial Resistance. Switzerland: World Health Organization; 2001. [cited 2012-01-15] http://whqlibdoc.who.int/hq/2001/WHO_CDS_CSR_DRS_2001.2.pdf

14. International Pharmaceutical Federation. FIP Statement of Policy Control of Antimicrobial Medicines Resistance (AMR). The Hague: International Pharmaceutical Federation; 2008. [cited 2012-01-15]. http://www.fip.org/www/uploads/database_file.php?id=289&table_id=

15. World Health Organization Regional Office for South-East Asia. Regional Strategy on Prevention and Containment of Antimicrobial Resistance 2010 – 2015. India: World Health Organization Regional Office for South-East Asia; 2010. [cited 2012-01-15] http://www.searo.who.int/LinkFiles/BCT_hlm-407.pdf.

16. Perbadanan Putrajaya. Official Portal of Perbadanan Putrajaya: Overall Summary. Putrajaya: Perbadanan Putrajaya. [updated 2012-11-27; cited 2012-11-28]. Available from: http://www.ppj.gov.my/portal/page?_pageid=311,1&_dad=portal&_schema=PORTAL#7804

17. McNulty CA, Boyle P, Nichols T, Clappison P, Davey P. Don’t wear me out – the public’s knowledge of and attitude to antibiotic use. J Antimicrob Chemother. 2007 February 16; 59(4): 727 – 738

18. Chen C, Chen YM, Hwang KL, Lin SJ, Yang CC, Tsay RW, Liu CE, Young TG. Behaviour, attitudes and knowledge about antibiotic usage among residents of Changhua, Taiwan. J Microbiol Immunol Infect. 2005 February; 38(1): 53 – 59.

19. Vanden Eng J, Marcus R, Hadler JL, Imhoff B, Vugia DJ, Cieslak PR, Zell E, Deneen V, McCombs KG, Zansky SM, Hawkins MA, Besser RE. Consumer attitudes and use of antibiotics. Emerg Infect Dis. 2003 September: 9(9): 1128 – 1135.

20. Raosoft. Sample Size Calculator. [cited 2010-01-18]. Available from: http://www.raosoft.com/samplesize.html

21. You JH, Yau B, Choi KC, Chau CT, Huang QR, Lee SS. Public knowledge, attitudes and behaviour on antibiotic use: a telephone survey in Hong Kong. Infection. 2008 March; 36(2): 153 – 157.

22. Kim SS, Moon S, Kim EJ. Public knowledge and attitudes regarding antibiotic use in South Korea. J Korean Acad Nurs 2011 December; 41(6): 742 – 749.

23. McNulty CA, Boyle P, Nichols T, Clappison P, Davey P. The public’s attitude to and compliance with antibiotics. J Antimicrob Chemother. 2007; 60 (Suppl 1): i63 – i68.

24. Pharmaceutical Services Division, Ministry of Health Malaysia. Know Your Medicine. Kuala Lumpur: Pharmaceutical Services Division [updated 2012-08-07; cited 2012-08-10]. Available from: www.knowyourmedicine.gov.my

25. Hawkings NJ, Wood F, Butler CC. Public attitudes towards bacterial resistance: a qualitative study. J Antimicrob Chemother. 2007 April 21; 59(6), 1155 – 1160.

26. Mölstad S, Erntell M, Hanberger H, Melander E, Norman C, Skoog G, Lundborg CS, Söderström A, Torell E, Cars O. Sustained reduction of antibiotic use and low bacterial resistance: 10-year follow-up of the Swedish Strama programme. Lancet Infect Dis. 2008 February; 8(2): 125 – 132.

27. Sabuncu E, David J, Bernède-Bauduin C, Pépin S, Leroy M, Boëlle P, Watier L, Guillemot D. Significant reduction of antibiotic use in the community after a nationwide campaign in France, 2002-2007. PLoS Med. 2009 June 2; 6(6) Epub ahead of print.

28. Altiner A, Brockmann S, Sielk M, Wilm S, Wegscheider K, Abholz HH. Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster-randomized intervention study. J Antimicrob Chemother. 2007 July 10; 60(3): 638 – 644.



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Antibiotics Malaysia